"That is happiness; to be disolved into something complete and great. When it comes to one, it comes as naturally as sleep." - Willa Cather

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Sunday, 6 March 2011

Giving Birth in The Gambia

So, I haven't actually been to The Gambia. I just enjoy saying it because it is one of the few countries that gets a The. Not even La France gets a The, even though they call themselves "The France".

Anyway, I finally went to my first appointment with my "earth mother" (jordmor) here in Denmark. This is the woman who is assigned to deliver our baby; the American/British equivalent is a midwife. Nobody here is assigned a doctor for delivery - unless for some reason you are pegged as having a high risk pregnancy. My first appointment was supposed to be around week 13, but because things are so backed up here, I had to wait until just before week 19.

I don't know what I was expecting - but I was expecting something. But she (actually there were two of them there) just talked to me. "Wow - that's great you run so much! You saved me time convincing you to exercise. You should take more iron. Here are some brochures about breastfeeding. Here's the number to call when you go in labor." They didn't weigh me, take my blood pressure, measure me. And then they were like - "well, since you're just two weeks away from the next appointment with us, we'll just skip that one and you can come back in week 29. See ya in the third trimester! Good luck! Keep running!"

I admit, I did get to listen to the fetal heart sound for the first time. Sure that was nice, but I knew it would have a heart beat since I feel it kick nearly hourly.

So I started thinking... is it actually dangerous to give birth in Denmark? I mean how they heck do the ever get the impression something is wrong?

And that's when I started thinking about giving birth in places like The Gambia. I did a bit of research and found their infant mortality rate is around the 31st highest in the world. Angola actually has the highest at almost 20%! So is Denmark even close to this? Of course not. Denmark's infant mortality rate is .46%, the 12th lowest in the world and is, not surprisingly, lower than that in the US (.63%). But this number isn't really that interesting when talking about giving birth. Infant mortality rate includes all deaths in the first year of life. Most infant deaths that occur in the third world are sometime later in that first year due to infection.

So what about actual birth outcomes? Everyone reading this knows that mothers and babies alike are much less likely to die at birth in the developed world than in the third world. But why is this? And what if I told you that in the 1940's the perinatal and maternal mortality in the US were similar to what they are in the 3rd world now (between 3 and 4%)? What is it then that has made the difference and what should all mothers worldwide have available when giving birth?

Unfortunately the answer is not at all simple. So much changed between the 40's and the 60's. Well, actually, the improvement is not that complicated when it comes to maternal death; that rate fell drastically after the introduction of penicillin in the 50's. But what about perinatal mortality? In developing countries, most perinatal mortality occurs due to the baby in some way getting stuck, the umbilical cord getting compressed and the baby asphyxiating before it can come out. A myriad of things came together at once in the 50's and 60's ensuring that this basically never happens in the developed world anymore: fetal heart rate monitors and people who know how to read them, quick access to a person skilled with forceps or a cesarean section with anesthesiologists and obstetricians. APGAR scores give an idea of how the baby is doing seconds after birth and neonatal intensivists are on hand to take over if the baby was not doing well. And prenatal ultrasounds give warning when there may be a problem in utero. This, along with many, many other little interventions, is the modern "obstetrical package". And it consists of so many elements that have never been analyzed separately, so it is tough to say what really made the difference. Today almost all perinatal mortality occurs due to premature birth, and with access to a neonatal intensive care unit, it is only the very, very premature that don't survive. And, in all honesty, when born before 25 weeks, most will lead a life fraught with disabilities and health problems (there are exceptions).

So, thankfully, I have access to all of these modern interventins here and that is why Denmark does just as well as The US (I should also mention that there are two sets of ultrasounds here - my second is next week) and for much less money.

But, when my earth mothers asked if I wanted to give birth at home, I said no, no, no. And why, if my water breaks before 33 weeks, I'm going to have SR drive me to Copenhagen - or I'll drive myself. I have to be near a good NICU.

Normally I am not one for much medical intervention. But I have worked in the 3rd world delivering babies - and have seen how frequently things can go wrong. I was involved in a case where the umbilical cord came out before the baby- the family doc there gave me a warm saline bottle to hold the cord in, so the cord wouldn't spasm in cold air and cut off the blood supply. I sat there for almost an hour in the middle of the night, with my hands between this woman's legs. She only spoke Tz'utujil , and well, a little Spanish, so we were able to very little small talk. The Fam Med doc, who normally would have had my help, set up for a c- section. Finally another family doc arrived to set up the anesthesia. We performed a c-section, the baby was delivered, and the mother could not stop hugging me. But an hour later, the baby started not breathing properly and not reacting right. I apologized to her, but I will never know if she understood. They were driven to Guatemala City and the baby died on the way.

This is not a reality people reading this blog deal with and if they ever did, they would sue. When the blood supply of a baby is compromised time is brain cells and very, very unfortunately nothing happened quickly that night.

It's probably good for me to put things in perspective - and admit that most of the things I talk about on this blog (exercise, weight gain, etc) are not factors that make a big difference in birth outcome.

The modern "obstetrical package" is one of the few examples in medicine of an group of interventions that has saved a huge amount of lives. But, the other side of this coin is that deliveries in the US (and Europe) have become over-medicalized. Women's labors are started if they go slightly past their due date. If labor is too slow or there is even a blip of heart-rate deceleration on the heart rate monitor, women are rushed to the OR for a c-section. Not based on evidence, but simply on the idea that one must "do everything" and "not take chances". I'm not criticizing; it is tough to make decisions when it's no longer ethical to due a study about not using one of the interventions.

To end this post on a running note, this is perhaps one of the biggest benefits of running while pregnant: much lower chance of emergency c-section. Babies heart rates don't decelerate - they are strong due to all of that blood flow variation they have gotten through their exercising mom. So doctors worry less. Also, babies of running moms are much less likely to be large for gestational age and, to some extent, they are less likely to go beyond their due date. Run for your own health - and run to avoid the risks of the overmedicalization of labor and delivery! But the real risk of problems at birth is dependent on where you live - not what you do.

I have to thank The WHO, The CIA, James Clapp and Atul Gawande for their writings and reports, which I used in this blog post.

And finally, since SR is in Portugal this weekend, I have turned to dreaming about singing a pop duet with Enrique Iglesias. My two running songs of the day were "Escape" and "Heartbeat" by Enrique Iglesias. The only downside is his lyrics are uninteresting. But they worked well on my long run- on the first warm day of the year in Denmark!

11 comments:

Lots of countries have "The" in their names, from The Czech Republic, to The United States of America to The People's Republic of China.

Risk of complications, especially during delivery, are all based on poverty. There's a shockingly high mortality rate in the US, given the quality of medical care available - to those who can afford it.

@SteveQ: Countries you mentioned have THE there because "republic", "states", "country" is included in their name and then you must use THE. But there are really only very few countries that have THE without rep, states etc in the name. I did not know that Gambia has THE, probably because one can say just Gambia and it is not a grammatical mistake. However, saying Netherlands without the THE, that's a mistake.

@SLG: You see, you found people in the medical/OB circles who support your decision to stay active!:)I have not done any research or anything, but I have read few stories about pregnant runners and their deliveries and it seems that most of them went past their due date. I have no numbers on this though, it was only my observation, maybe it was just a coincidence. But I thought wow, it must have something to do with mothers being active. Have you done any actual research about due dates and exercise?

Great that you found medical people who believe that exercise is okay (and important) during pregnancy, having this during my pregnancy was so nice. I think it would be great if more midwives were able to deliver in the US (at least in MN) to decrease the "medicalization" of birth. I wanted my labor/birth to be as natural as possible, but still have all the interventions if I needed.

I agree with Steve, the risk of complications in the US is high with the medical care available, but very much based on economic level.

(somewhat along the lines of mmmonyka's comment)I had gone so far as to think of The United States, The United Arab Emirates, The United Kingdom and The Phillipines - but take a look at South America and Africa: not a single The there except The Gambia. And all of the other "the's" seem to have something plural about them, thus somehow deserving a "the".

I admit that my source for the US's infant mortality rate was questionnable - couldn't find it listed with WHO or CIA. I had expected it to be higher than what I wrote.

Mmmonyka, I took the delivery info from a James Clapp study where 100 exercising women were matched with 100 non-exercising woman who were the same age and same socioeconomic status. The exercising women had the greatest chance of delivering in week 39, the non-exercising in week 40 (the study actually made me wonder if due dates are actually "naturally" a little earlier than 40 weeks, but that's all my speculation).

Marathon Mom,

I totally agree. I loved my midwife in the US. There is no need for everyone to have an OB-GYN as long as there is one available - it seems like this may be the direction the US is going, too. That would be good and so unlike the US to save money!

Have you read Birth Day by Mark Sloan? It's a pediatrician's account of the science, history, and "wonder" of childbirth. I am sure you already know all the science but don't know how much history you got in medical school. He compares and contrasts the crazy things we Americans insist upon with what the rest of the developed world does with respect to medical care and childbirth. P.S. Thank you for your blog!!! I am 21 weeks along with my first and nobody but my husband gets/supports my running habit.

Sarah, thanks so much for commenting. That sounds like a book I would like - and one thing for sure is I don't know all of the science behind anything :). Probably no medical school puts enought weigth on history; the only way one can begin to understand science and medicine is through history.

And now that I'm done pontificating on such sophisticated matters, it sucks that you friends and family don't get your running in pregnancy. Thank goodness for your hubby! And if your doctor/midwife doesn't support it, I would love to have a little discussion with them! Good luck in your pregnancy - and maybe consider starting a blog. You'll suddenly find a whole community of people "get" your running while pregnanct :).

Steve Q! I SAID The United Arab Emirates! Add to the list The Faroe Islands and my plural theory holds with the exception of republics. I am starting to think "gambia" means collection of tribes or some sort of plural concept. Nope - looked it up: the country is called The Republic of The Gambia because it is the country of the Gambia River. It IS an outlier in that it is named after the river The Gambia! Mystery solved.

Glaven, I simply refuse to refer to y'all as THEE Glaven (one of you in there must understand). I prefer That Glaven. Much more condescending.

I go to a practice in the US that is half midwives, half OB/GYNs, but I see one of the midwives. Idea is that the OB's are always there, on call, if you need one, but otherwise you just stick to the midwife. I think this is SO fantastic and it's a shame it's not more widely available in the US. With my first pregnancy/birth, I went to a practice of only OB/Gyns. When I switched for my second pregnancy, I asked the midwife what she perceived the major difference to be between the midwives and the doctors, seeing as how all of the prenatal testing and appointments were basically the same. She said, "we just treat pregnancy and birth as a normal process that's part of one's life, not as a medical condition that needs to be 'dealt with' (unless individual circumstances would dictate otherwise)." That makes so much sense to me.

Unrelated: I don't think you meant this, but I think your post makes it sound like not going past one's due date should be considered a good thing, as opposed to just a neutral thing from a medical standpoint. I was confused by that. Both of my girls were born past their supposed due dates, and other than feeling uncomfortable at the end of pregnancy (as all moms do), I was fine with that. I think there's too much focus on due dates in the U.S. and not enough of letting the baby come out when it's good and ready. I have no studies to point to but do think that the rise of inductions is statistically correlated to a higher incidence of unplanned c-sections. I know some people have valid reasons for inducing, but I'm of the opinion that most would be better off by just sticking it out and waiting.

Thanks so much for the comment. And I completely agree with you. Sometimes it is hard to word things right. I don't think there is anything unhealthy about going over the due date. I simply (agree with you again) think that too many women are induced. Not that this is necessarily unsafe, but I've certainly witnessed enough to know it's very unpleasant and I would always personally refuse being induced. The other problem with going over the date is the baby gets larger and c-sections are deemed necessary more often because of that. Again, nothing in and of itself unhealthy - but I still look at giving birth slightly before 40 weeks as an advantage because of the way modern obstetrics is. There. Hope that made sense.

Hello from Rude Skov

Photo by Stine Sophie Winckel

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My name is Tracy. I am a physician scientist from the USA, living with my husband and two young boys in Denmark. I work as a post-doc fellow at Næstved Hospital. I have a scientific interest in vision loss, vision loss during exercise, exercise, running during pregnancy, MAF training as well as nutrition and health for athletes. I also have a love for music, physics, statistics, cycling, yoga, cross-country skiing, bla bla bal.

I was a member of Team USA at the IAU World Championships in Ultra Trail Running in 2013 in Wales. I am now training to run with Team Denmark at the IAU World Championships in Annency, France in May 2015.